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 Table of Contents     
LETTER TO THE EDITOR
Year : 2019  |  Volume : 15  |  Issue : 1  |  Page : 90-91
 

The use of double CO2 insufflators in transanal total mesorectal excision: An alternative possibility


Department of Human Pathology of Adult and Evolutive Age, University Hospital of Messina, Messina, Italy

Date of Submission14-Mar-2018
Date of Acceptance18-Mar-2018
Date of Web Publication4-Dec-2018

Correspondence Address:
Dr. Giuseppe Currò
Department of Human Pathology of Adult and Evolutive Age, University Hospital of Messina, Via Consolare Valeria 1, 98100 Messina
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_26_18

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How to cite this article:
Lazzara C, Navarra G, Currò G. The use of double CO2 insufflators in transanal total mesorectal excision: An alternative possibility. J Min Access Surg 2019;15:90-1

How to cite this URL:
Lazzara C, Navarra G, Currò G. The use of double CO2 insufflators in transanal total mesorectal excision: An alternative possibility. J Min Access Surg [serial online] 2019 [cited 2018 Dec 14];15:90-1. Available from: http://www.journalofmas.com/text.asp?2019/15/1/90/231911


To the Editor,

Total mesorectal excision (TME) is the gold standard for the treatment of rectal cancer. The laparoscopic technique presents some limiting factors based on the characteristics of the patients and the tumour. To overcome these limits, surgeons tried a different approach for the surgical resection of mid or low rectal tumours and developed a new technique: transanal TME (TaTME).[1] A key step to perform TaTME is the creation of pneumorectum to obtain a clear surgical field. Two important hitches encountered by the most expert TaTME surgeons worldwide are related to some limitations of standard CO2 insufflators in obtaining and maintaining an excellent transanal endoscopic operative field: the excessive diathermy-induced smoke in an already confined surgical field and the billowing, ‘breathing’ or ‘unstable pneumorectum’ due to fluctuations in insufflation pressure.[2]

Conventional mechanical insufflators produce continuous and cycling pressure swinging within the surgical field. It happens because they consist of a single-lumen tube that alternates between CO2 gas insufflation for roughly 3 s, rest for 1 s to value pressure and re-insufflation to preserve the set pressure. In the TaTME procedure, the small surgical field enhances the nuisance problem of rectal billowing. Even minimum changes in pressure are remarkable and technically complicate the procedure. Another important issue is the diathermy-induced smoke and its elimination. With conventional insufflators, smoke is evacuated opening a valve, modifying intraluminal pressure and determining significant pumping of the rectal tissue. These factors lead to a constant readjustment and camera cleaning that tire out the surgeon. Consequently, the procedure takes longer and the correct identification of tissue planes is hindered. It can expose pelvic sidewall structures, urethra, nervi erigentes and mesorectal package at risk of injury, particularly in case of bleeding.[3] Although many high-performance insufflators are now available on the market, the AirSeal® System (AirSeal, ConMed, Inc., Utica, NY, USA) seems to be distinct from others.[4],[5] It is characterised by one valveless AirSeal trocar connected with a three-lumen filter tube set that works in concert to recirculate CO2 gas into the surgical cavity. One lumen provides of CO2 influx, the second lumen supplies outflow and the third lumen provides real-time monitoring and preservation of set pressure. The recirculation of insufflated CO2 that complies with patients' pelvic temperature and humidity guarantees a less fogging of the camera view. Furthermore, the AirSeal® System instantly reacts to the minimum changes in the set pressure adapting flow rate in real time, avoiding billowing of pneumorectum. Although it seems the best setup option to perform the pneumorectum in the TaTME procedure, the AirSeal® System has also some shortages: the rigidity of the insufflation tube impedes port ideal location in a limited space; the AirSeal® trocar cannula has to be collocated in the upper part of the GelPOINT® platform to avoid filter canister dysfunction due to the aspiration of a large amount of fluid and finally, the cost of the AirSeal® System device is very high. Here, we present an alternative, intermediate setup. We use two CO2 conventional insufflators at the same time: the first one connected to the 12 mm trocar and the second one directly connected to the GelPOINT® platform [Figure 1]. The double contemporary insufflation has several advantages as it bypasses the ‘single-tube’ limitation typical of conventional insufflators. The contemporary use of two standard insufflators interrupts the cyclical pressure fluctuation of traditional laparoscopic insufflators. The desynchronisation of the insufflators' cycles achieves a more stable pneumorectum. Furthermore, the nearly continuous inflow of CO2 reduces the ‘breathing’ of rectal mucosa due to the smoke evacuation. As a result, both surgical smoke and pumping of the rectal tissue are highly reduced. The economic advantage of our alternative setup has to be taken into account. Using two conventional insufflators is cheaper than the AirSeal® System consumables. Further technical aspects of this setup include the fogging of the camera view. The continuous addiction of fresh, cold CO2 rather than recirculating insufflated CO2 does not ensure AirSeal® clearness of the view. Our alternative technique enables the surgeon to concentrate on surgical dissection of the correct tissue planes, avoiding distractions due to loss of pneumorectum, fluctuating pressure, pausing to clean the camera or continuous smoke discharges. A further application of this technique is necessary to confirm its intermediary role between conventional insufflation and AirSeal® System in obtaining an excellent surgical field in a confined space like in the TaTME procedure.
Figure 1: The double contemporary insufflation through the GelPOINT® in transanal total mesorectal excision

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vennix S, Pelzers L, Bouvy N, Beets GL, Pierie JP, Wiggers T, et al. Laparoscopic versus open total mesorectal excision for rectal cancer. Cochrane Database Syst Rev 2014;4:CD005200.  Back to cited text no. 1
    
2.
Velthuis S, van den Boezem PB, van der Peet DL, Cuesta MA, Sietses C. Feasibility study of transanal total mesorectal excision. Br J Surg 2013;100:828-31.  Back to cited text no. 2
    
3.
Rouanet P, Mourregot A, Azar CC, Carrere S, Gutowski M, Quenet F, et al. Transanal endoscopic proctectomy: An innovative procedure for difficult resection of rectal tumors in men with narrow pelvis. Dis Colon Rectum 2013;56:408-15.  Back to cited text no. 3
    
4.
Heald RJ. A new solution to some old problems: Transanal TME. Tech Coloproctol 2013;17:257-8.  Back to cited text no. 4
    
5.
Nicholson G, Knol J, Houben B, Cunningham C, Ashraf S, Hompes R, et al. Optimal dissection for transanal total mesorectal excision using modified CO2 insufflation and smoke extraction. Colorectal Dis 2015;17:O265-7.  Back to cited text no. 5
    


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2004 Journal of Minimal Access Surgery
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